Basic Information
| Provider Information | |||||||||
| NPI: | 1255987327 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OMALLEY | ||||||||
| FirstName: | NOLAN | ||||||||
| MiddleName: | SHAWN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1732 N PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984068110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396921569 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5814 GRAHAM AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | SUMNER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983902728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538917093 | ||||||||
| FaxNumber: | 2538911033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2019 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60962719 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 60962719 | 01 | WA | PT LICENSE | OTHER |